When can Chronic Myeloid Leukemia (CML) patients on dasatinib (Sprycel) be taken for surgery?

Timing of Surgery for CML Patients on Dasatinib

CML patients on dasatinib should proceed to surgery when their absolute neutrophil count (ANC) is ≥1.0 × 10⁹/L and platelets are ≥50 × 10⁹/L, with dasatinib held perioperatively and resumed postoperatively once counts recover to these thresholds. 1

Preoperative Blood Count Requirements

The European LeukemiaNet guidelines establish clear hematologic thresholds for dasatinib management that directly inform surgical timing:

• Minimum ANC: ≥1.0 × 10⁹/L 1
• Minimum platelet count: ≥50 × 10⁹/L for chronic phase CML 1
• For advanced phase disease: ANC ≥1.0 × 10⁹/L and platelets ≥20 × 10⁹/L 1

These represent the recovery thresholds used for resuming dasatinib after drug-induced cytopenias, making them appropriate safety margins for surgical procedures.

Perioperative Dasatinib Management Algorithm

Step 1: Assess baseline counts

• Obtain complete blood count within 1 week of planned surgery 1
• If counts meet thresholds above, proceed with surgical planning 1

Step 2: Hold dasatinib preoperatively

• Discontinue dasatinib at least 24-48 hours before surgery to minimize bleeding risk 1
• Dasatinib causes reversible inhibition of platelet aggregation that contributes to bleeding 1

Step 3: Monitor for pleural effusion

• Pleural effusion occurs in 28-33% of dasatinib patients and is a critical preoperative consideration 1, 2
• Patients with prior cardiac history, hypertension, or advanced age have higher risk 1, 2
• Symptomatic pleural effusion should be managed before elective surgery 1

Step 4: Postoperative resumption

• Resume dasatinib once ANC ≥1.0 × 10⁹/L and platelets ≥50 × 10⁹/L (chronic phase) or ≥20 × 10⁹/L (advanced phase) 1
• Monitor blood counts weekly for first 4-6 weeks after resumption 1

Critical Perioperative Considerations

Bleeding risk management:

• Dasatinib's platelet dysfunction is reversible but clinically significant 1
• The once-daily 100 mg dosing has lower thrombocytopenia rates (23%) compared to twice-daily 70 mg dosing (38%) 1
• Consider hematology consultation for high-bleeding-risk procedures 1

Cardiovascular complications:

• Screen for pulmonary arterial hypertension (PAH), which occurs in 5% of dasatinib patients 2
• Evaluate for pleural effusion with chest imaging if respiratory symptoms present 1, 2
• PAH and pleural effusion can complicate anesthesia and postoperative recovery 2, 3

Drug interactions:

• Avoid CYP3A4 inhibitors perioperatively as they increase dasatinib exposure and toxicity 2
• Medications prolonging QT interval require caution 2

Common Pitfalls to Avoid

Do not proceed with elective surgery if:

• ANC <1.0 × 10⁹/L or platelets <50 × 10⁹/L 1
• Symptomatic pleural effusion is present 1, 2
• Active infection or uncontrolled CML is present 1

Do not resume dasatinib postoperatively until:

• Blood counts meet recovery thresholds 1
• Surgical site hemostasis is secure 1
• Patient can tolerate oral medications 1

Emergency Surgery Considerations

For urgent/emergency surgery when counts are suboptimal:

• Proceed with surgery if benefits outweigh risks 1
• Provide platelet transfusion support if platelets <50 × 10⁹/L 1
• Consider granulocyte colony-stimulating factor if ANC <0.5 × 10⁹/L 1
• Maintain close hematology involvement throughout perioperative period 1